Transgender patients on rise, but medical care and services lag

Dr. Matthew Leinung, director of the Division of Endocrinology and Metabolism, at his office on Monday, Nov. 14, 2011, at Albany Medical Center Endocrinology Group in Albany, N.Y. (Cindy Schultz / Times Union)

Dr. Matthew Leinung, director of the Division of Endocrinology and Metabolism, at his office on Monday, Nov. 14, 2011, at Albany Medical Center Endocrinology Group in Albany, N.Y. (Cindy Schultz / Times Union)

Photo: Cindy Schultz

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Dr. Matthew Leinung, director of the Division of Endocrinology and Metabolism, at his office on Monday, Nov. 14, 2011, at Albany Medical Center Endocrinology Group in Albany, N.Y. (Cindy Schultz / Times Union)

Dr. Matthew Leinung, director of the Division of Endocrinology and Metabolism, at his office on Monday, Nov. 14, 2011, at Albany Medical Center Endocrinology Group in Albany, N.Y. (Cindy Schultz / Times Union)

Photo: Cindy Schultz

Transgender patients on rise, but medical care and services lag

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ALBANY — Doctors don't learn how to treat transgender patients in medical school and the medical establishment has been slow to address a rising trend, according to a local physician.

When Dr. Matthew Leinung, an endocrinologist and professor of medicine, joined the Albany Medical Center staff in 1991, he took over a practice from Dr. David Goodman, who had been seeing a half-dozen transgender patients beginning in the 1970s.

"He (Goodman) was the only one who would treat them at the time in this area and he asked me if I was OK taking those patients," Leinung recalled. "I said I didn't have any problem with it, but I didn't know anything about treating them."

Goodman recommended one of the few clinical volumes available on the topic, a text on endocrine treatment of transgender persons by Dr. Louis Gooren, a Dutch endocrinologist considered a pioneer in the field.

By word of mouth, the number of transgender patients in Leinung's Albany practice began to rise and it has continued to climb during the past 20 years and he has seen more than 300 patients.

The increase has been so dramatic in the past few years that Leinung, the primary endocrinologist treating transgender patients in the Capital Region, has maxed out and cannot accept new transgender patients in a practice that includes an overwhelming majority of diabetics.

"The need is huge and I do this work because I've seen success stories," Leinung said. "It's not an easy road, but some of my patients have made a positive transition."

Although the American Psychiatric Association classifies it as a gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders, Leinung has worked to remove the stigma of mental illness.

The clinical definition — "a persistent aversion toward some or all of those physical characteristics or social roles that connote one's own biological sex" — does not begin to capture Leinung's experience with transgender patients.

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HOW IT WORKS

Hormone replacement therapy, explained by Dr. Matthew Leinung:

"The physical differences between men and women are due to the effects of male and female sex hormones (testosterone and estrogen respectively). At puberty, production of these hormones increases dramatically, leading to establishment of adult male and female body types. Some of these changes are irreversible, such as larger skeletal size or the development of breasts. The goal of hormonal therapy in transsexuals is to induce those physical changes that have not occurred because of lack of exposure to cross-gender hormones (for example, inducing facial hair growth in female-to-male transsexuals). Surgery is used for physical changes that are irreversible, such as breast development.

"Sex hormone production is tightly regulated in adults through a feedback system (think of a thermostat and furnace heating a house). When sex hormones are administered to someone, this will cause suppression of hormone production by the testes or ovaries (similar to a space heater in the house leading to the furnace turning off). For male to female patients, oral administration of ample doses of estradiol (the main estrogen) leads to replacement of testosterone with estradiol, and subsequent stimulation of female physical changes. Similarly, in female to male patients, administration of testosterone (usually done with weekly or biweekly injections) replaces estrogens with testosterone, and subsequent development of male characteristics. In essence, the attempt is to induce puberty of the opposite sex. This process takes two to four years to replicate."

"It's a very complicated area and there has not been much research into it," Leinung said.

The analogy he likes to use is that each person has a switch in the brain that controls a person's gender identity and a sense of seeing yourself as either male or female.

"For transgender people, the switch is thrown in the opposite direction and they've always felt uncomfortable in the gender role they took on through socialization beginning at birth," Leinung said.

In his male-to-female patients, who represent about 80 percent of his caseload, hormone replacement therapy involves reducing male characteristics such as body hair, beard growth, muscular upper body development, pattern hair loss on the scalp and other masculine physical attributes. Drug therapies enhance the feminization process by increasing breast development, fullness in the hips, a softer skin texture and other female characteristics. Leinung balances the blocking of testosterone and the increase of estrogen while monitoring side effects.

"I work with my patients so they can be recognized by society in the gender they feel they truly are," Leinung said.

Each person's time frame and transition goals are different. Only about 30 percent of his patients undergo some type of gender-related surgery, ranging from breast augmentation to gender reassignment surgery.

His patients average five years from the start of hormone therapy to completion of surgery, although some decide to wait for up to 15 years before going under the knife.

Several patients he has seen for more than two decades have not yet committed to surgery, but continue to receive hormone therapy.

A new trend for Leinung's practice is transgender patients coming for treatment at a younger age.

"If they come to me at 20, they don't have as much societal baggage to overcome compared to someone who begins to transition in his 50s or 60s," Leinung said. The drug therapies are also more effective and act more quickly on younger transgender patients.

But major obstacles remain for his patients. Discrimination and isolation due to social stigma still runs high. Among his transgender patients, about 40 percent are unemployed. Many tell bleak stories about workplace discrimination and being fired when they began showing up at the office in a different gender.

There is also a barrier to medical care for transgender patients, since Medicaid and some private health insurance policies are declining coverage for various types of transgender care.

"Access to care is a major issue," Leinung said. "If we allow access at a younger age and let them start therapy, our experience is that they will not continue to have as many psychiatric issues, they'll become more employable and they'll have better outcomes. All-around, the adjustment to society is much better at a younger age."

Leinung presented his data and testified before a state panel advising Gov. Andrew Cuomo on proposed Medicaid reforms.

"I made the argument to the panel that Medicaid should cover hormone therapy, treatment and surgery," Leinung said. "Transsexuals feel abandoned. Gays and lesbians have won several major victories lately, while transsexuals have been left behind."